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Arshad MF, Walkinshaw E, Solomon AL, Bernjak A, Rombach I, Leelarathna L, Little SA, Evans M, Shaw JAM, Heller SR, Iqbal A. Diabetic autonomic neuropathy does not impede improvement in hypoglycaemia awareness in adults: Sub-study results from the HypoCOMPaSS trial. Diabet Med 2024:e15340. [PMID: 38741266 DOI: 10.1111/dme.15340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/22/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
AIMS Impaired awareness of hypoglycaemia (IAH) increases the risk of severe hypoglycaemia in people with type 1 diabetes mellitus (T1DM). IAH can be reversed through meticulous avoidance of hypoglycaemia. Diabetic autonomic neuropathy (DAN) has been proposed as an underlying mechanism contributing to IAH; however, data are inconsistent. The aim of this study was to examine the effects of cardiac autonomic neuropathy (CAN) on IAH reversibility inT1DM. METHODS Participants with T1DM and IAH (Gold score ≥4) recruited to the HypoCOMPaSS (24-week 2 × 2 factorial randomised controlled) trial were included. All underwent screening for cardiac autonomic function testing at baseline and received comparable education and support aimed at avoiding hypoglycaemia and improving hypoglycaemia awareness. Definite CAN was defined as the presence of ≥2 abnormal cardiac reflex tests. Participants were grouped according to their CAN status, and changes in Gold score were compared. RESULTS Eighty-three participants (52 women [62.7%]) were included with mean age (SD) of 48 (12) years and mean HbA1c of 66 (13) mmol/mol (8.2 [3.3] %). The mean duration of T1DM was 29 (13) years. The prevalence of CAN was low with 5/83 (6%) participants having definite autonomic neuropathy with 11 (13%) classified with possible/early neuropathy. All participants, regardless of the autonomic function status, showed a mean improvement in Gold score of ≥1 (mean improvement -1.2 [95% CI -0.8, -1.6]; p < 0.001). CONCLUSIONS IAH can be improved in people with T1DM, and a long duration of disease, with and without cardiac autonomic dysfunction. These data suggest that CAN is not a prime driver for modulating IAH reversibility.
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Affiliation(s)
- Muhammad Fahad Arshad
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Emma Walkinshaw
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | | | | | | | - Lala Leelarathna
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Stuart A Little
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Mark Evans
- MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - James A M Shaw
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Simon R Heller
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Ahmed Iqbal
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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Davis TME, Tan E, Davis WA. Prevalence and prognostic significance of cardiac autonomic neuropathy in community-based people with type 2 diabetes: the Fremantle Diabetes Study Phase II. Cardiovasc Diabetol 2024; 23:102. [PMID: 38500197 PMCID: PMC10949593 DOI: 10.1186/s12933-024-02185-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/01/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND There is a paucity of contemporary data on the prevalence and prognostic significance of cardiac autonomic neuropathy (CAN) from community-based cohorts with type 2 diabetes assessed using gold standard methods. The aim of this study was to assess these aspects of CAN in the longitudinal observational Fremantle Diabetes Study Phase II (FDS2). METHODS FDS2 participants were screened at baseline using standardised cardiovascular reflex tests (CARTs) of heart rate variation during deep breathing, Valsalva manoeuvre and standing. CAN (no/possible/definite) was assessed from the number of abnormal CARTs. Multinomial regression identified independent associates of CAN status. Cox proportional hazards modelling determined independent baseline predictors of incident heart failure (HF) and ischaemic heart disease (IHD), and all-cause mortality. RESULTS Of 1254 participants assessed for CAN, 86 (6.9%) were outside CART age reference ranges and valid CART data were unavailable for 338 (27.0%). Of the remaining 830 (mean age 62.3 years, 55.3% males, median diabetes duration 7.3 years), 51.0%, 33.7% and 15.3% had no, possible or definite CAN, respectively. Independent associates of definite CAN (longer diabetes duration, higher body mass index and resting pulse rate, antidepressant and antihypertensive therapies, albuminuria, distal sensory polyneuropathy, prior HF) were consistent with those reported previously. In Kaplan-Meier analysis, definite CAN was associated with a lower likelihood of incident IHD and HF versus no/possible CAN (P < 0.001) and there was a graded increase in all-cause mortality risk from no CAN to possible and definite CAN (P < 0.001). When CAN category was added to the most parsimonious models, it was not a significant independent predictor of IHD (P ≥ 0.851) or HF (P ≥ 0.342). Possible CAN (hazard ratio (95% CI) 1.47 (1.01, 2.14), P = 0.046) and definite CAN (2.42 (1.60, 3.67), P < 0.001) increased the risk of all-cause mortality versus no CAN. CONCLUSIONS Routine screening for CAN in type 2 diabetes has limited clinical but some prognostic value.
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Affiliation(s)
- Timothy M E Davis
- Medical School, Fremantle Hospital, University of Western Australia, PO Box 480, Fremantle, WA, 6959, Australia.
- Department of Endocrinology and Diabetes, Fiona Stanley and Fremantle Hospitals, Murdoch, WA, Australia.
- Australian Centre for Accelerating Diabetes Innovations (ACADI), The University of Melbourne, Melbourne, VIC, Australia.
| | - Eva Tan
- Medical School, Fremantle Hospital, University of Western Australia, PO Box 480, Fremantle, WA, 6959, Australia
| | - Wendy A Davis
- Medical School, Fremantle Hospital, University of Western Australia, PO Box 480, Fremantle, WA, 6959, Australia
- Australian Centre for Accelerating Diabetes Innovations (ACADI), The University of Melbourne, Melbourne, VIC, Australia
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Chen Y, Gong Y, Cai K. Correlations of cardiovascular autonomic neuropathy with urinary albumin excretion rate and cardiac function in patients with type 2 diabetes mellitus. Minerva Endocrinol (Torino) 2024; 49:3-12. [PMID: 33792236 DOI: 10.23736/s2724-6507.21.03358-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The associations of cardiovascular autonomic neuropathy (CAN) with diabetic nephropathy and heart disease remain elusive. The aim of this study was to explore the correlations of CAN with urinary albumin excretion rate (UAER) and cardiac function in patients with type 2 diabetes mellitus (T2DM). METHODS A total of 225 T2DM patients were assigned into CAN and non-CAN groups using cardiovascular reflex tests (CARTs). They were divided into macroalbuminuria, microalbuminuria and normoalbuminuria groups according to urinary albumin/creatinine ratio (UACR), or left ventricular diastolic dysfunction and normal groups based on left ventricular peak E/A velocity ratio (E/A). The correlations of CAN with albuminuria and left ventricular diastolic dysfunction, and the predictive values of UACR and E/A were analyzed. RESULTS Compared with non-CAN group, CAN group had older age, longer T2DM duration, higher serum urine acid (SUA) level, UACR, systolic and diastolic pressure differences between supine and standing positions, and lower other CARTs parameters and E/A (P<0.001). Macroalbuminuria group had largest positional systolic and diastolic pressure differences, and lowest other CARTs parameters (P<0.001). Compared with normal group, left ventricular diastolic dysfunction group had larger positional systolic and diastolic pressure differences, and lower other CARTs parameters (P<0.001). CAN in T2DM patients was positively correlated with albuminuria and left ventricular diastolic dysfunction (P<0.001). Age, SUA, UACR and E/A were independent predictive factors (P=0.031, P=0.005, P<0.001, P<0.001). UACR and E/A had high predictive values. CONCLUSIONS In T2DM patients, CAN is positively correlated with declined UAER and cardiac function. UACR and E/A have high predictive values.
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Affiliation(s)
- Yunjiang Chen
- Department of General Practice, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanchun Gong
- Department of General Practice, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kaiyu Cai
- Department of General Practice, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China -
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Huang Y, Xie P, Zhang S, Liu M, Huang R, Xiong Z, Zhong X, Lin Y, Zhou Z, Zhang W, Guo Y, Yang D, Zhuang X, Liao X. Intensive Glycemic Therapy in Type 2 Diabetes Patients With Cardiac Autonomic Dysfunction: The ACCORD Trial. Mayo Clin Proc 2024; 99:90-101. [PMID: 37690012 DOI: 10.1016/j.mayocp.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE To assess whether the presence of cardiac autonomic dysfunction denoted by low heart rate variability (HRV) modifies the effect of intensive glycemic therapy on outcomes in patients with type 2 diabetes. PATIENTS AND METHODS This study included 7946 participants in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial from January 2001 through June 2009. Heart rate variability measures included standard deviation of all normal-to-normal intervals (SDNN) and root mean square of successive differences between normal-to-normal intervals (rMSSD). Abnormal values were defined based on less than the 10th percentile for SDNN and rMSSD. RESULTS Compared with standard therapy, intensive therapy was associated with improved primary outcome (composite of cardiovascular events) in the low-HRV group (SDNN: HR, 0.57; 95% CI, 0.39 to 0.84; rMSSD: HR, 0.57; 95% CI, 0.38 to 0.84), but not in the normal-HRV group (SDNN: HR, 0.90; 95% CI, 0.77 to 1.05; rMSSD: HR, 0.90; 95% CI, 0.77 to 1.05). A similar pattern was found for coronary heart disease. Conversely, intensive therapy had a neutral effect on all cause death in the low-HRV group (SDNN: HR, 0.88; 95% CI, 0.54 to 1.41; rMSSD: HR, 0.71; 95% CI, 0.43 to 1.17;), but increase risk of all-cause death in the normal-HRV group (SDNN: HR, 1.21; 95% CI, 1.00 to 1.46; rMSSD: HR, 1.25; 95% CI, 1.03 to 1.51). Intensive therapy induced a greater risk of hypoglycemia in the normal-HRV group than that in the low-HRV group. CONCLUSION Cardiac autonomic dysfunction expressed as low HRV identified subpopulations in ACCORD with more benefits and less harms from intensive therapy.
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Affiliation(s)
- Yiquan Huang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Peihan Xie
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Shaozhao Zhang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Menghui Liu
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Rihua Huang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Zhenyu Xiong
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Xiangbin Zhong
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Yifen Lin
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Ziwei Zhou
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Wenjing Zhang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Yue Guo
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Daya Yang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China
| | - Xiaodong Zhuang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China.
| | - Xinxue Liao
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, and the NHC Key Laboratory of Assisted Circulation, Sun Yat-Sen University, Guangzhou, China.
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Hajdu M, Garmpis K, Vértes V, Vorobcsuk-Varga N, Molnár GA, Hejjel L, Wittmann I, Faludi R. Determinants of the heart rate variability in type 1 diabetes mellitus. Front Endocrinol (Lausanne) 2023; 14:1247054. [PMID: 37854193 PMCID: PMC10579906 DOI: 10.3389/fendo.2023.1247054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/04/2023] [Indexed: 10/20/2023] Open
Abstract
Background Evaluation of heart rate variability (HRV) detects the early subclinical alterations of the autonomic nervous system. Thus, impaired HRV is the earliest subclinical marker of cardiac autonomic neuropathy (CAN) in type 1 diabetes mellitus (T1DM). Objectives We aimed to explore the HRV parameters in asymptomatic T1DM patients and compare them with the results obtained in healthy subjects. Potential associations between HRV parameters and the established risk factors for CAN and cardiovascular diseases were also investigated. Methods Seventy T1DM patients (38 ± 12 years, 46 females) and 30 healthy subjects were enrolled into the study. For HRV analysis, beat-to-beat heart rate was recorded for 30 min. The less noisy 5-min segment of the recording was analyzed by Bittium Cardiac Navigator HRV analysis software. Time domain, frequency domain, and nonlinear indices were calculated. Results Regarding ratio of low to high frequency component (LF/HF), no differences were found between the two populations (p = 0.227). All the further, time domain, frequency domain, and nonlinear HRV indices were significantly lower in T1DM patients (each p < 0.001). In multiple linear models, disease duration remained the only independent predictor of LF/HF ratio (p = 0.019). HbA1c was found to be significant independent predictor of all further time domain (SDNN, p < 0.001; rMSSD, p < 0.001), frequency domain (VLF, p < 0.001; LF, p = 0.002; HF, p = 0.006; Total Power, p = 0.002), and nonlinear indices (SD1, p = 0.006; SD2, p = 0.007), alone, or in combination with other factors, such as age or body mass index. Conclusion Asymptomatic T1DM patients have significantly reduced overall HRV as compared with healthy subjects, indicating subclinical CAN. Quality of the glycemic control is important determinant of HRV among T1DM patients. This relationship is independent of other risk factors for CAN or cardiovascular diseases.
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Affiliation(s)
- Máté Hajdu
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | | | - Vivien Vértes
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | | | - Gergő Attila Molnár
- 2nd Department of Internal Medicine and Nephrological Center, Medical School, University of Pécs, Pécs, Hungary
| | - László Hejjel
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - István Wittmann
- 2nd Department of Internal Medicine and Nephrological Center, Medical School, University of Pécs, Pécs, Hungary
| | - Réka Faludi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
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Hansen CS, Rasmussen DGK, Hansen TW, Nielsen SH, Theilade S, Karsdal MA, Genovese F, Rossing P. Collagen turnover is associated with cardiovascular autonomic and peripheral neuropathy in type 1 diabetes: novel pathophysiological mechanism? Cardiovasc Diabetol 2023; 22:158. [PMID: 37386485 PMCID: PMC10311721 DOI: 10.1186/s12933-023-01891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Diabetic cardiovascular autonomic neuropathy (CAN) and distal symmetrical polyneuropathy (DSPN) are severe diabetic complications. Collagen type VI (COL6) and III (COL3) have been associated with nerve function. We investigated if markers of COL6 formation (PRO-C6) and COL3 degradation (C3M) were associated with neuropathy in people with type 1 diabetes (T1D). METHODS In a cross-sectional study including 300 people with T1D, serum and urine PRO-C6 and C3M were obtained. CAN was assessed by cardiovascular reflex tests: heart rate response to deep breathing (E/I ratio), to standing (30/15 ratio) and to the Valsalva maneuver (VM). Two or three pathological CARTs constituted CAN. DSPN was assessed by biothesiometry. Symmetrical vibration sensation threshold above 25 V constituted DSPN. RESULTS Participants were (mean (SD)) 55.7 (9.3) years, 51% were males, diabetes duration was 40.0 (8.9) years, HbA1c was 63 (11 mmol/mol, (median (IQR)) serum PRO-C6 was 7.8 (6.2;11.0) ng/ml and C3M 8.3 (7.1;10.0) ng/ml. CAN and DSPN were diagnosed in 34% and 43% of participants, respectively. In models adjusted for relevant confounders a doubling of serum PRO-C6, was significantly associated with odds ratio > 2 for CAN and > 1 for DSPN, respectively. Significance was retained after additional adjustments for eGFR only for CAN. Higher serum C3M was associated with presence of CAN, but not after adjustment for eGFR. C3M was not associated with DSPN. Urine PRO-C6 analyses indicated similar associations. CONCLUSIONS Results show previously undescribed associations between markers of collagen turnover and risk of CAN and to a lesser degree DSPN in T1D.
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Affiliation(s)
- Christian S. Hansen
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2-4, 2820 Gentofte, Denmark
| | | | - Tine W. Hansen
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2-4, 2820 Gentofte, Denmark
| | - Signe Holm Nielsen
- Nordic Bioscience, Herlev, Denmark
- Technical University of Denmark, Lyngby, Denmark
| | - Simone Theilade
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2-4, 2820 Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2-4, 2820 Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Brock C, Wegeberg AM, Nielsen TA, Karout B, Hellström PM, Drewes AM, Vorum H. The Retinal Nerve Fiber Layer Thickness Is Associated with Systemic Neurodegeneration in Long-Term Type 1 Diabetes. Transl Vis Sci Technol 2023; 12:23. [PMID: 37367720 DOI: 10.1167/tvst.12.6.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Purpose To determine whether the retinal nerve fiber layer thickness can be used as an indicator for systemic neurodegeneration in diabetes. Methods We used existing data from 38 adults with type 1 diabetes and established polyneuropathy. Retinal nerve fiber layer thickness values of four scanned quadrants (superior, inferior, temporal, and nasal) and the central foveal thickness were extracted directly from optical coherence tomography. Nerve conduction velocities were recorded using standardized neurophysiologic testing of the tibial and peroneal motor nerves and the radial and median sensory nerves, 24-hour electrocardiographic recordings were used to retrieve time- and frequency-derived measures of heart rate variability, and a pain catastrophizing scale was used to assess cognitive distortion. Results When adjusted for hemoglobin A1c, the regional thickness of the retinal nerve fiber layers was (1) positively associated with peripheral nerve conduction velocities of the sensory and motor nerves (all P < 0.036), (2) negatively associated with time and frequency domains of heart rate variability (all P < 0.033), and (3) negatively associated to catastrophic thinking (all P < 0.038). Conclusions Thickness of the retinal nerve fiber layer was a robust indicator for clinically meaningful measures of peripheral and autonomic neuropathy and even for cognitive comorbidity. Translational Relevance The findings indicate that the thickness of the retinal nerve fiber layer should be studied in adolescents and people with prediabetes to determine whether it is useful to predict the presence and severity of systemic neurodegeneration.
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Affiliation(s)
- Christina Brock
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg, Denmark
| | - Anne-Marie Wegeberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Thisted Research Unit, Aalborg University Hospital Thisted, Thisted, Denmark
| | - Thomas Arendt Nielsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Per M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg, Denmark
| | - Henrik Vorum
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark
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Nattero-Chávez L, Insenser M, Quintero Tobar A, Fernández-Durán E, Dorado Avendaño B, Fiers T, Kaufman JM, Luque-Ramírez M, Escobar-Morreale HF. Sex differences and sex steroids influence on the presentation and severity of cardiovascular autonomic neuropathy of patients with type 1 diabetes. Cardiovasc Diabetol 2023; 22:32. [PMID: 36793089 PMCID: PMC10127589 DOI: 10.1186/s12933-023-01766-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Sex differences characterize cardiovascular outcomes in patients with type 1 diabetes. Cardioautonomic neuropathy is a common complication of type 1 diabetes that associates increased morbi-mortality. Data regarding the interplay between sex and cardiovascular autonomic neuropathy are scarce and controversial in these patients. We aimed to address sex-related differences in the prevalence of seemingly asymptomatic cardioautonomic neuropathy in type 1 diabetes, and their associations with sex steroids. METHODS We conducted a cross-sectional study including 322 consecutively recruited patients with type 1 diabetes. Cardioautonomic neuropathy was diagnosed using Ewing's score and power spectral heart rate data. We assessed sex hormones by liquid chromatography/tandem mass spectrometry. RESULTS When considering all subjects as a whole, asymptomatic cardioautonomic neuropathy prevalence was not significantly different between women and men. When age was taken into account, the prevalence of cardioautonomic neuropathy was similar among young men and those > 50 years. However, in women > 50 years, the prevalence of cardioautonomic neuropathy doubled that of young women [45.8% (32.6; 59.7) vs. 20.4% (13.7; 29.2), respectively]. The OR of having cardioautonomic neuropathy was 3.3 higher in women > 50 years than in their younger counterparts. Furthermore, women presented more severe cardioautonomic neuropathy than men. These differences were even more marked when women were classified according their menopausal status instead of age. Peri- and menopausal women had an OR 3.5 (1.7; 7.2) of having CAN compared with their reproductive-aged counterparts [CAN prevalence: 51% (37; 65) vs. 23% (16; 32), respectively]. A binary logistic regression model (R2: 0.161; P = 0.001) displayed age > 50 years as a significant determinant of cardioautonomic neuropathy only in women. Androgens were positively associated with heart rate variability in men, and negatively in women. Accordingly, cardioautonomic neuropathy was associated with increased testosterone/estradiol ratio in women but to decreased testosterone concentrations in men. CONCLUSIONS Menopause in women with type 1 diabetes is accompanied by an increase in the prevalence of asymptomatic cardioautonomic neuropathy. This age-related excess risk of cardioautonomic neuropathy is not observed in men. Men and women with type 1 diabetes have opposite associations between circulating androgens and indexes of cardioautonomic function. Trial registration ClinicalTrials.gov Identifier: NCT04950634.
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Affiliation(s)
- Lía Nattero-Chávez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Carretera de Colmenar, Km 9.1, 28034, Madrid, Spain.,Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
| | - María Insenser
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
| | - Alejandra Quintero Tobar
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Fernández-Durán
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Dorado Avendaño
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Carretera de Colmenar, Km 9.1, 28034, Madrid, Spain
| | - Tom Fiers
- Laboratory for Hormonology and Department of Endocrinology, Ghent University Hospital, 9000, Ghent, Belgium
| | - Jean-Marc Kaufman
- Laboratory for Hormonology and Department of Endocrinology, Ghent University Hospital, 9000, Ghent, Belgium
| | - Manuel Luque-Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Carretera de Colmenar, Km 9.1, 28034, Madrid, Spain. .,Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain. .,University of Alcalá, Madrid, Spain.
| | - Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Carretera de Colmenar, Km 9.1, 28034, Madrid, Spain.,Laboratory for Hormonology and Department of Endocrinology, Ghent University Hospital, 9000, Ghent, Belgium.,University of Alcalá, Madrid, Spain
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Amelioration of Diabetes and Neuropathy After Pancreas Transplantation: Measurable Differences in Vibration Perception Thresholds Impact Outcomes. Transplantation 2023; 107:309-310. [PMID: 35969038 DOI: 10.1097/tp.0000000000004276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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10
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Cardoso CRL, de Oliveira VAG, Leite NC, Salles GF. Prognostic importance of cardiovascular autonomic neuropathy on cardiovascular and mortality outcomes in individuals with type 2 diabetes: The Rio de Janeiro type 2 diabetes cohort. Diabetes Res Clin Pract 2023; 196:110232. [PMID: 36563882 DOI: 10.1016/j.diabres.2022.110232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/04/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
AIMS To investigate whether tests for cardiovascular autonomic neuropathy (CAN) and 24-hour heart rate variability (HRV) could improve the prediction for outcomes in type 2 diabetes. METHODS 541 type 2 diabetic individuals performed tests of CAN. A subsample (313) had 24-hour HRV (the standard deviation of all normal RR intervals [SDNN] and the standard deviation of the averaged normal RR intervals for all 5 min segments [SDANN]). Multivariate Cox regressions examined the associations between CAN/low HRV with cardiovascular events (CVEs) and all-cause mortality. The improvement in risk discrimination of adding CAN/HRV was tested by C-statistics and by the Integrated Discrimination Improvement (IDI) index. RESULTS 25% had CAN, and 17-18% had low HRV, respectively by SDANN-SDNN. Over a median follow-up of 12 years, there were 177 CVEs and 236 all-cause deaths in the whole cohort, and 96 CVEs and 129 all-cause deaths in the subsample. CAN was associated with 40% excess risks of CVEs/all-cause mortality, low HRV was associated with 2-fold higher risks of outcomes. HRV improved risk discrimination for CVEs/mortality with increases in C-statistics up to 0.039 and IDIs up to 25%. CONCLUSIONS Low HRV was a better predictor of outcomes than tests of CAN, and it improved risk discrimination.
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Affiliation(s)
- Claudia R L Cardoso
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Brazil.
| | - Vinicius A G de Oliveira
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Brazil
| | - Nathalie C Leite
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Brazil
| | - Gil F Salles
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Brazil
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Diabetic Neuropathy Is Independently Associated With Worse Graft Outcomes and Incident Cardiovascular Disease After Pancreas Transplantation: A Retrospective Cohort Study in Type 1 Diabetes. Transplantation 2023; 107:475-484. [PMID: 35969040 DOI: 10.1097/tp.0000000000004275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Information about the impact of diabetic neuropathy (DN) on outcomes after pancreas transplantation (PT) is scarce. We assessed the independent relationship between DN markers with both graft survival and incident cardiovascular disease (CVD) after transplantation. METHODS A cohort study in individuals with type 1 diabetes and end-stage kidney disease who underwent PT between 1999 and 2015 was conducted. DN was assessed with vibration perception thresholds (VPTs) and orthostatic hypotension (pre-PT and 6 mo, 2-3, 5-6, and 8-10 y after transplantation). Pretransplantation and posttransplantation DN markers were related with graft failure/dysfunction and incident CVD during follow-up. RESULTS We included 187 participants (70% men, age 39.9 ± 7.1 y, diabetes duration 27.1 y), with a median follow-up of 11.3 y. Abnormal VPTs (≥25 V) were observed in 53%. After transplantation, VPTs improved (22.4 ± 8.4 pretransplant versus 16.1 ± 6.1 V at 8-10 y post-PT; P < 0.001); additionally, the prevalence of abnormal VPTs decreased (53% pretransplant versus 24.4% at 8-10 y; P < 0.001). After adjusting for age, sex, diabetes duration, blood pressure, body mass index, and previous CVD, pretransplant VPTs ≥25 V were independently associated with pancreas graft failure/dysfunction (hazard ratio [HR], 2.01 [1.01-4.00]) and incident CVD (HR, 2.57 [1.17-5.64]). Furthermore, persistent abnormal VPTs after 6 mo posttransplantation were associated with the worst outcomes (HR, 2.80 [1.25-6.23] and HR, 3.19 [1.14-8.96], for graft failure/dysfunction and incident CVD, respectively). CONCLUSIONS In individuals with type 1 diabetes and end-stage kidney disease, PT was associated with an improvement of VPTs. This simple and widely available DN study was independently associated with pancreas graft function and CVD posttransplantation.
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Onder Camas A, Özel ŞK, Kocabey Sütçü Z, Hepokur M, Emeksiz HC. Evaluation of bladder dysfunction in children and adolescents with type 1 diabetes mellitus by uroflowmetry. J Pediatr Endocrinol Metab 2023; 36:25-28. [PMID: 36412007 DOI: 10.1515/jpem-2022-0503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/05/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Diabetic cystopathy is a condition characterized by decreased bladder sensitivity, increased bladder capacity, decreased bladder contractility and increased residual urine volume. It can also be considered as an early indicator of autonomic dysfunction. In this study, it was aimed to evaluate bladder functions by uroflowmetry in children and adolescents with the diagnosis of type 1 diabetes mellitus. METHODS Type 1 diabetes mellitus children and adolescents were applied uroflowmetry and post-void residual urine volumes were evaluated. The physical examination findings of the patients and the laboratory data of diabetes control were obtained from the clinic files. RESULTS A total of 51 cases aged 72-216 (155.6 ± 35.4) months were enrolled into the study. Diabetes age of the cases was 66.5 ± 46.2(13-180) months. The last one year average of HbA1c of the patients was found to be 9.7 ± 1.9%. A total of 9.8% had good, 39.2% moderate and 51% poor metabolic control, respectively. While urodynamic evaluation was normal in 36 (70.6%) of 51 participants, voiding dysfunction was found in 15. There was no statistically significant difference between groups with and without voiding dysfunction in terms of age, gender, duration of diabetes, metabolic control and HbA1c values. CONCLUSIONS It is very important to follow up patients with type 1 diabetes mellitus in terms of autonomic dysfunction. Diabetic bladder clinic, which can be observed independently of diabetes duration and metabolic control, is also included in this status. Urodynamic evaluation will be helpful both in demonstrating bladder dysfunction and in preventing possible complications.
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Affiliation(s)
- Asan Onder Camas
- Pediatric Endocrinology Clinic, Medeniyet University Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Şeyhmus Kerem Özel
- Pediatric Surgery Clinic, Medeniyet University Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Zümrüt Kocabey Sütçü
- Pediatric Endocrinology Clinic, Medeniyet University Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Merve Hepokur
- Pediatric Endocrinology Clinic, Medeniyet University Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Hamdi Cihan Emeksiz
- Pediatric Endocrinology Clinic, Medeniyet University Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
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Sacchetta L, Chiriacò M, Nesti L, Leonetti S, Forotti G, Natali A, Solini A, Tricò D. Synergistic effect of chronic kidney disease, neuropathy, and retinopathy on all-cause mortality in type 1 and type 2 diabetes: a 21-year longitudinal study. Cardiovasc Diabetol 2022; 21:233. [DOI: 10.1186/s12933-022-01675-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
The prognostic value of common and frequently associated diabetic microvascular complications (MVC), namely chronic kidney disease (CKD), cardiac autonomic neuropathy (CAN), peripheral neuropathy (DPN), and retinopathy (DR), is well established. However, the impact of their different combinations on long-term mortality has not been adequately assessed.
Methods
We retrospectively analyzed 21-year longitudinal data from 303 patients with long-standing type 1 (T1D) or type 2 diabetes (T2D), who were thoroughly characterized at baseline for the presence of MVC using 99mTc-DTPA dynamic renal scintigraphy, overnight urine collection, cardiovascular autonomic tests, monofilament testing, and dilated fundus oculi examination.
Results
After a 5,244 person-years follow-up, a total of 133 (43.9%) deaths occurred. The presence of CKD and CAN, regardless of other MVC, increased the adjusted all-cause mortality risk by 117% (HR 2.17 [1.45–3.26]) and 54% (HR 1.54 [1.01–2.36]), respectively. Concomitant CKD&CAN at baseline were associated with the highest mortality risk (HR 5.08 [2.52–10.26]), followed by CKD&DR (HR 2.95 [1.63–5.32]), and CAN&DR (HR 2.07 [1.11–3.85]). Compared with patients free from MVC, the mortality risk was only numerically higher in those with any isolated MVC (HR 1.52 [0.87–2.67]), while increased by 203% (HR 3.03 [1.62–5.68]) and 692% (HR 7.92 [2.93–21.37]) in patients with two and three concomitant MVC, respectively.
Conclusions
Our study demonstrates the long-term, synergistic, negative effects of single and concomitant diabetic MVC on all-cause mortality, which should encourage comprehensive screenings for MCV in both T1D and T2D to improve risk stratification and treatment.
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Physical activity trajectories, autonomic balance and cognitive function: The Coronary Artery Risk Development in Young Adults (CARDIA) study. Prev Med 2022; 164:107291. [PMID: 36209818 DOI: 10.1016/j.ypmed.2022.107291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/27/2022] [Accepted: 10/02/2022] [Indexed: 11/23/2022]
Abstract
Physical activity (PA) plays an important role in cognitive health. However, the underlying mechanisms are not fully understood. Cardiac autonomic balance is influenced by PA and implicated in dementia pathogenesis. We examined whether autonomic balance mediates the association between PA and cognitive function. The sample included 1939 participants from the Coronary Artery Risk Development in Young Adults study who completed cognitive testing after 30-year follow-up (baseline: mean age 25.2 ± 3.5y; 58% women; 43% Black). Moderate to vigorous intensity PA (MVPA) was obtained in 7 consecutive examinations over 20 years (Year 0-Year 20). Cardiac autonomic balance was assessed at Year 20 via resting heart rate (RHR), standard deviation normal to normal (SDNN) and root mean square of successive differences (RMSSD). We used group-based trajectory modeling to identify homogenous MVPA trajectory groups, and formal mediation analysis to test whether autonomic function indices mediate the association between MVPA trajectories and cognition. We identified three distinct PA trajectory patterns: (1) Below MVPA guidelines (n = 1122; 57.9%); (2) Meeting MVPA guidelines (n = 652; 33.6%); and (3) Exceeding MVPA guidelines (n = 165; 8.5%). Meeting and exceeding MVPA guidelines were related to better autonomic balance overall, and to improved semantic fluency performance. Statistically, the association between higher MVPA level and verbal ability was mediated by SDNN and RMSSD, but not by RHR. In our sample of young and middle-aged adults, higher MVPA levels over time were associated with better cardiac autonomic function, which explained some of the associations between PA trajectories and better cognition.
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 136] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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Cardiac Autonomic Neuropathy in Type 1 and 2 Diabetes: Epidemiology, Pathophysiology, and Management. Clin Ther 2022; 44:1394-1416. [DOI: 10.1016/j.clinthera.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 07/23/2022] [Accepted: 09/06/2022] [Indexed: 11/21/2022]
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Abdalrada AS, Abawajy J, Al-Quraishi T, Islam SMS. Machine learning models for prediction of co-occurrence of diabetes and cardiovascular diseases: a retrospective cohort study. J Diabetes Metab Disord 2022; 21:251-261. [PMID: 35673486 PMCID: PMC9167176 DOI: 10.1007/s40200-021-00968-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/29/2021] [Indexed: 12/15/2022]
Abstract
Background Diabetic mellitus (DM) and cardiovascular diseases (CVD) cause significant healthcare burden globally and often co-exists. Current approaches often fail to identify many people with co-occurrence of DM and CVD, leading to delay in healthcare seeking, increased complications and morbidity. In this paper, we aimed to develop and evaluate a two-stage machine learning (ML) model to predict the co-occurrence of DM and CVD. Methods We used the diabetes complications screening research initiative (DiScRi) dataset containing >200 variables from >2000 participants. In the first stage, we used two ML models (logistic regression and Evimp functions) implemented in multivariate adaptive regression splines model to infer the significant common risk factors for DM and CVD and applied the correlation matrix to reduce redundancy. In the second stage, we used classification and regression algorithm to develop our model. We evaluated the prediction models using prediction accuracy, sensitivity and specificity as performance metrics. Results Common risk factors for DM and CVD co-occurrence was family history of the diseases, gender, deep breathing heart rate change, lying to standing blood pressure change, HbA1c, HDL and TC\HDL ratio. The predictive model showed that the participants with HbA1c >6.45 and TC\HDL ratio > 5.5 were at risk of developing both diseases (97.9% probability). In contrast, participants with HbA1c >6.45 and TC\HDL ratio ≤ 5.5 were more likely to have only DM (84.5% probability) and those with HbA1c ≤5.45 and HDL >1.45 were likely to be healthy (82.4%. probability). Further, participants with HbA1c ≤5.45 and HDL <1.45 were at risk of only CVD (100% probability). The predictive accuracy of the ML model to detect co-occurrence of DM and CVD is 94.09%, sensitivity 93.5%, and specificity 95.8%. Conclusions Our ML model can significantly predict with high accuracy the co-occurrence of DM and CVD in people attending a screening program. This might help in early detection of patients with DM and CVD who could benefit from preventive treatment and reduce future healthcare burden.
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Monnier VM, Sell DR, Gao X, Genuth SM, Lachin JM, Bebu I. Plasma advanced glycation end products and the subsequent risk of microvascular complications in type 1 diabetes in the DCCT/EDIC. BMJ Open Diabetes Res Care 2022; 10:10/1/e002667. [PMID: 35058313 PMCID: PMC8783825 DOI: 10.1136/bmjdrc-2021-002667] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/01/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION To assess impact of glycemic control on plasma protein-bound advanced glycation end products (pAGEs) and their association with subsequent microvascular disease. RESEARCH DESIGN AND METHODS Eleven pAGEs were measured by liquid chromatography-mass spectrometry in banked plasma from 466 participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study at three time points (TPs): DCCT year 4 (TP1) and year 8 (TP2) and EDIC year 5/6 (TP3). Correlation coefficients assessed cross-sectional associations, and Cox proportional hazards models assessed associations with subsequent risk of microvascular complications through EDIC year 24. RESULTS Glucose-derived glycation products fructose-lysine (FL), glucosepane (GSPN) and carboxymethyl-lysine (CML) decreased with intensive glycemic control at both TP1 and TP2 (p<0.0001) but were similar at TP3, and correlated with hemoglobin A1c (HbA1c). At TP1, the markers were associated with the subsequent risk of several microvascular outcomes. These associations did not remain significant after adjustment for HbA1c, except methionine sulfoxide (MetSOX), which remained associated with diabetic kidney disease. In unadjusted models using all 3 TPs, glucose-derived pAGEs were associated with subsequent risk of proliferative diabetic retinopathy (PDR, p<0.003), clinically significant macular edema (CSME, p<0.015) and confirmed clinical neuropathy (CCN, p<0.018, except CML, not significant (NS)). Adjusted for age, sex, body mass index, diabetes duration and mean updated HbA1c, the associations remained significant for PDR (FL: p<0.002, GSPN: p≤0.02, CML: p<0.003, pentosidine: p<0.02), CMSE (CML: p<0.03), albuminuria (FL: p<0.02, CML: p<0.03) and CCN (FL: p<0.005, GSPN : p<0.003). CONCLUSIONS pAGEs at TP1 are not superior to HbA1c for risk prediction, but glucose-derived pAGEs at three TPs and MetSOX remain robustly associated with progression of microvascular complications in type 1 diabetes even after adjustment for HbA1c and other factors.
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Affiliation(s)
- Vincent M Monnier
- Pathology and Biochemistry, Case Western Reserve University Department of Pathology, Cleveland, Ohio, USA
| | - David R Sell
- Pathology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Xiaoyu Gao
- The Biostatistics Center, The George Washington University, Rockville, Maryland, USA
| | - Saul M Genuth
- Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - John M Lachin
- The Biostatistics Center, The George Washington University, Rockville, Maryland, USA
| | - Ionut Bebu
- The Biostatistics Center, The George Washington University, Rockville, Maryland, USA
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Hansen CS, Suvitaival T, Theilade S, Mattila I, Lajer M, Trošt K, Ahonen L, Hansen TW, Legido-Quigley C, Rossing P, Ahluwalia TS. Cardiovascular Autonomic Neuropathy in Type 1 Diabetes Is Associated With Disturbances in TCA, Lipid, and Glucose Metabolism. Front Endocrinol (Lausanne) 2022; 13:831793. [PMID: 35498422 PMCID: PMC9046722 DOI: 10.3389/fendo.2022.831793] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/11/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Diabetic cardiovascular autonomic neuropathy (CAN) is associated with increased mortality and morbidity. To explore metabolic mechanisms associated with CAN we investigated associations between serum metabolites and CAN in persons with type 1 diabetes (T1D). MATERIALS AND METHODS Cardiovascular reflex tests (CARTs) (heart rate response to: deep breathing; lying-to-standing test; and the Valsalva maneuver) were used to diagnose CAN in 302 persons with T1D. More than one pathological CARTs defined the CAN diagnosis. Serum metabolomics and lipidomic profiles were analyzed with two complementary non-targeted mass-spectrometry methods. Cross-sectional associations between metabolites and CAN were assessed by linear regression models adjusted for relevant confounders. RESULTS Participants were median (IQR) aged 55(49, 63) years, 48% males with diabetes duration 39(32, 47) years, HbA1c 63(55,69) mmol/mol and 34% had CAN. A total of 75 metabolites and 106 lipids were analyzed. In crude models, the CAN diagnosis was associated with higher levels of hydroxy fatty acids (2,4- and 3,4-dihydroxybutanoic acids, 4-deoxytetronic acid), creatinine, sugar derivates (ribitol, ribonic acid, myo-inositol), citric acid, glycerol, phenols, phosphatidylcholines and lower levels of free fatty acids and the amino acid methionine (p<0.05). Upon adjustment, positive associations with the CAN diagnoses were retained for hydroxy fatty acids, tricarboxylic acid (TCA) cycle-based sugar derivates, citric acid, and phenols (P<0.05). CONCLUSION Metabolic pathways, including the TCA cycle, hydroxy fatty acids, phosphatidylcholines and sugar derivatives are associated with the CAN diagnosis in T1D. These pathway may be part of the pathogeneses leading to CAN and may be modifiable risk factors for the complication.
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Affiliation(s)
- Christian S. Hansen
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- *Correspondence: Christian S. Hansen,
| | - Tommi Suvitaival
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Simone Theilade
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The Department of Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Ismo Mattila
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Maria Lajer
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Kajetan Trošt
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Linda Ahonen
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Tine W. Hansen
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | | | - Peter Rossing
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tarunveer S. Ahluwalia
- Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- The Bioinformatics Center, Department of Biology, University of Copenhagen, Copenhagen, Denmark
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Pop‐Busui R, Backlund JC, Bebu I, Braffett BH, Lorenzi G, White NH, Lachin JM, Soliman EZ. Utility of using electrocardiogram measures of heart rate variability as a measure of cardiovascular autonomic neuropathy in type 1 diabetes patients. J Diabetes Investig 2022; 13:125-133. [PMID: 34309223 PMCID: PMC8756321 DOI: 10.1111/jdi.13635] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 01/02/2023] Open
Abstract
AIMS/INTRODUCTION Cardiovascular autonomic neuropathy (CAN) is a predictor of cardiovascular disease and mortality. Cardiovascular reflex tests (CARTs) are the gold standard for the diagnosis of CAN, but might not be feasible in large research cohorts or in clinical care. We investigated whether measures of heart rate variability obtained from standard electrocardiogram (ECG) recordings provide a reliable measure of CAN. MATERIALS AND METHODS Standardized CARTs (R-R response to paced breathing, Valsalva, postural changes) and digitized 12-lead resting ECGs were obtained concomitantly in Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications participants (n = 311). Standard deviation of normally conducted R-R intervals (SDNN) and the root mean square of successive differences between normal-to-normal R-R intervals (rMSSD) were measured from ECG. Sensitivity, specificity, probability of correct classification and Kappa statistics evaluated the agreement between ECG-derived CAN and CARTs-defined CAN. RESULTS Participants with CARTs-defined CAN had significantly lower SDNN and rMSSD compared with those without CAN (P < 0.001). The optimal cut-off points of ECG-derived CAN were <17.13 and <24.94 ms for SDNN and rMSSD, respectively. SDNN plays a dominant role in defining CAN, with an area under the curve of 0.73, indicating fair test performance. The Kappa statistic for SDNN was 0.41 (95% confidence interval 0.30-0.51) for the optimal cut-off point, showing fair agreement with CARTs-defined CAN. Combining SDNN and rMSSD optimal cut-off points does not provide additional predictive power for CAN. CONCLUSIONS These analyses are the first to show the agreement between indices of heart rate variability derived from ECGs and the gold standard CARTs, thus supporting potential use as a measure of CAN in clinical research and clinical care.
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Affiliation(s)
- Rodica Pop‐Busui
- Department of Internal MedicineDivision of Metabolism, Endocrinology and DiabetesUniversity of MichiganAnn ArborMichiganUSA
| | - Jye‐Yu C Backlund
- Biostatistics CenterThe George Washington UniversityRockvilleMarylandUSA
| | - Ionut Bebu
- Biostatistics CenterThe George Washington UniversityRockvilleMarylandUSA
| | - Barbara H Braffett
- Biostatistics CenterThe George Washington UniversityRockvilleMarylandUSA
| | - Gayle Lorenzi
- University of California San DiegoLa JollaCaliforniaUSA
| | | | - John M Lachin
- Biostatistics CenterThe George Washington UniversityRockvilleMarylandUSA
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center (EPICARE)Department of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Department of MedicineSection on CardiologyWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
- Institute of Global Health and Human EcologySchool of Science and EngineeringAmerican University in CairoCairoEgypt
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Gibbons CH, Silvestri NJ. Autonomic Dysfunction in Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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22
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Autonomic Testing Optimizes Therapy for Heart Failure and Related Cardiovascular Disorders. Curr Cardiol Rep 2022; 24:1699-1709. [PMID: 36063349 PMCID: PMC9442559 DOI: 10.1007/s11886-022-01781-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular autonomic control is an intricately balanced dynamic process. Autonomic dysfunction, regardless of origin, promotes and sustains the disease processes, including in patients with heart failure (HF). Autonomic control is mediated through the two autonomic branches: parasympathetic and sympathetic (P&S). HF is arguably the disease that stands to most benefit from P&S manipulation to reduce mortality risk. This review article briefly summarizes some of the more common types of autonomic dysfunction (AD) that are found in heart failure, suggests a mechanism by which AD may contribute to HF, reviews AD involvement in common HF co-morbidities (e.g., ventricular arrhythmias, AFib, hypertension, and Cardiovascular Autonomic Neuropathy), and summarizes possible therapy options for treating AD in HF. RECENT FINDINGS Autonomic assessment is important in diagnosing and treating CHF, and its possible co-morbidities. Autonomic assessment may also have importance in predicting which patients may be susceptible to sudden cardiac death. This is important since most CHF patients with sudden cardiac death have preserved left ventricular ejection fraction and better discriminators are needed. Many life-threatening cardiovascular disorders will require invasive testing for precise diagnoses and therapy planning when modulating the ANS is important. In cases of non-life-threatening disorders, non-invasive ANS testing techniques, especially those that individually assess both ANS branches simultaneously and independently, are sufficient to diagnose and treat serially.
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23
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Chowdhury M, Nevitt S, Eleftheriadou A, Kanagala P, Esa H, Cuthbertson DJ, Tahrani A, Alam U. Cardiac autonomic neuropathy and risk of cardiovascular disease and mortality in type 1 and type 2 diabetes: a meta-analysis. BMJ Open Diabetes Res Care 2021; 9:9/2/e002480. [PMID: 34969689 PMCID: PMC8719152 DOI: 10.1136/bmjdrc-2021-002480] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/14/2021] [Indexed: 01/24/2023] Open
Abstract
We aimed to determine the prognostic association between cardiac autonomic neuropathy (CAN) and cardiovascular disease events (CVE) and mortality in type 1 and type 2 diabetes through a systematic review and meta-analysis. This systematic review and meta-analysis was registered with PROSPERO (CRD42020216305) and was conducted with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodological criteria. CAN was defined on the basis of 1 (early/possible CAN) or ≥2 (definite CAN) positive autonomic function tests as per the Toronto Consensus guidelines. Studies included those with prospective CVE or mortality data. Methodological variables/risk of bias were assessed using ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) and RoB-2 (Risk-Of-Bias tool for randomized trials) appraisal tools. Electronic database searches yielded 18 467 articles; 84 articles were screened full-text, 26 articles fulfilled the inclusion criteria for quantitative synthesis. Sixteen studies from patients with (n=2875) and without (n=11 722) CAN demonstrated a pooled relative risk (RR) of 3.16 (95%CI 2.42 to 4.13; p<0.0001) of future CVE in favour of CAN. Nineteen studies provided all-cause mortality data from patients with (n=3679) and without (n=12 420) CAN, with a pooled RR of 3.17 (95%CI 2.11 to 4.78; p<0.0001) in favour of CAN. The risk of both future CVE and mortality was higher in type 1 compared with type 2 diabetes and with a definite CAN (vs possible CAN) diagnosis. Three studies were considered to have risk of serious bias. This study confirms the significant association between CAN and CVE and all-cause mortality. The implementation of population-based CAN screening will identify a subgroup with disproportionately higher cardiovascular and mortality risk that will allow for earlier targeted intervention.
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Affiliation(s)
- Mahin Chowdhury
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | - Sarah Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | | | - Prathap Kanagala
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
| | - Hani Esa
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
| | - Daniel J Cuthbertson
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
| | - Abd Tahrani
- Centre of Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
- Department of Medicine, University Hospital Aintree, Liverpool University NHS Foundation Trust, Liverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
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24
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Dependence of Heart Rate Variability Indices on the Mean Heart Rate in Women with Well-Controlled Type 2 Diabetes. J Clin Med 2021; 10:jcm10194386. [PMID: 34640404 PMCID: PMC8509544 DOI: 10.3390/jcm10194386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 12/15/2022] Open
Abstract
Heart rate variability (HRV) is a method used to evaluate the presence of cardiac autonomic neuropathy (CAN) because it is usually attributed to oscillations in cardiac autonomic nerve activity. Recent studies in other pathologies suggest that HRV indices are strongly related to mean heart rate, and this does not depend on autonomic activity only. This study aimed to evaluate the correlation between the mean heart rate and the HRV indices in women patients with well-controlled T2DM and a control group. HRV was evaluated in 19 T2DM women and 44 healthy women during basal supine position and two maneuvers: active standing and rhythmic breathing. Time-domain (SDNN, RMSSD, pNN20) and frequency-domain (LF, HF, LF/HF) indices were obtained. Our results show that meanNN, age, and the maneuvers are the main predictors of most HRV indices, while the diabetic condition was a predictor only for pNN20. Given the known reduced HRV in patients with T2DM, it is clinically important that much of the HRV indices are dependent on heart rate irrespective of the presence of T2DM. Moreover, the multiple regression analyses evidenced the multifactorial etiology of HRV.
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25
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Marcovecchio ML. Importance of Identifying Novel Biomarkers of Microvascular Damage in Type 1 Diabetes. Mol Diagn Ther 2021; 24:507-515. [PMID: 32613289 DOI: 10.1007/s40291-020-00483-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Microvascular complications of type 1 diabetes, which primarily include diabetic kidney disease, retinopathy, and neuropathy, are characterized by damage to the microvasculature of the kidney, retina, and neurons. The pathogenesis of these complications is multifactorial, and several pathways are implicated. These complications are often silent during their early stages, and once symptoms develop, there might be little to be done to cure them. Thus, there is a strong need for novel biomarkers to identify individuals at risk of microvascular complications at an early stage and guide the implementation of new therapeutic options for preventing their development and progression. Recent advancements in proteomics, metabolomics, and other 'omics' have led to the identification of several potential biomarkers of microvascular complications. However, biomarker discovery has met several challenges and, up to now, there are no new biomarkers that have been implemented into clinical practice. This highlights the need for further work in this area to move towards better diagnostic and prognostic approaches.
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Affiliation(s)
- M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge, Level 8, Box 116, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
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26
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Ang L, Kidwell KM, Dillon B, Reiss J, Fang F, Leone V, Mizokami-Stout K, Pop-Busui R. Dapagliflozin and measures of cardiovascular autonomic function in patients with type 2 diabetes (T2D). J Diabetes Complications 2021; 35:107949. [PMID: 34024686 DOI: 10.1016/j.jdiacomp.2021.107949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/03/2021] [Accepted: 05/07/2021] [Indexed: 01/08/2023]
Abstract
AIMS Sodium-glucose cotransporter-2 (SGLT-2) inhibitors reduce blood pressure without compensatory heart rate elevation, possibly by modulating sympathetic/parasympathetic activity. This may contribute to their cardiovascular benefits in type 2 diabetes (T2D). We evaluated the effects of dapagliflozin (DAPA) on measures of cardiovascular autonomic neuropathy (CAN), cardiac function, and glucose variability (GV) in T2D. METHODS Pilot, randomized, two-period crossover trial comparing 12-week DAPA versus 12-week glimepiride treatment on CAN measures (cardiovascular autonomic reflex tests and heart rate variability), B-type natriuretic peptide (BNP), and GV (Abbott's Libre Pro devices) using signed rank tests and mixed models from baseline to 12 weeks within and between each period. RESULTS Forty-five T2D participants on metformin monotherapy (mean age 57 ± 8 years, duration 7 ± 6 years, HbA1c 7.8 ± 1.3%) were enrolled with 41 completing the trial. There were no differences in CAN indices or BNP with each drug compared to baseline and each other. Participants on DAPA demonstrated greater weight loss, reduced time in hypoglycemia, and improved GV compared to glimepiride. CONCLUSIONS Short term treatment with DAPA did not affect CAN measures or BNP in uncomplicated and relatively healthy T2D participants. Longer prospective studies in patients with advanced disease are needed to better understand relationships between SGLT-2 inhibitors and CAN. CLINICAL TRIAL REGISTRATION NCT02973477.
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Affiliation(s)
- Lynn Ang
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America.
| | - Kelley M Kidwell
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States of America
| | - Brendan Dillon
- University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Jacob Reiss
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Fang Fang
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States of America
| | - Virginia Leone
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Kara Mizokami-Stout
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America; Ann Arbor Veteran Affairs Hospital, Ann Arbor, MI, United States of America
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
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27
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Sirtuin 1, Visfatin and IL-27 Serum Levels of Type 1 Diabetic Females in Relation to Cardiovascular Parameters and Autoimmune Thyroid Disease. Biomolecules 2021; 11:biom11081110. [PMID: 34439776 PMCID: PMC8391548 DOI: 10.3390/biom11081110] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 12/19/2022] Open
Abstract
The loss of cardioprotection observed in premenopausal, diabetic women may result from the interplay between epigenetic, metabolic, and immunological factors. The aim of this study was to evaluate the concentration of sirtuin 1, visfatin, and IL-27 in relation to cardiovascular parameters and Hashimoto’s disease (HD) in young, asymptomatic women with type 1 diabetes mellitus (T1DM). Thyroid ultrasound, carotid intima-media thickness (cIMT) measurement, electrocardiography, and echocardiography were performed in 50 euthyroid females with T1DM (28 with HD and 22 without concomitant diseases) and 30 controls. The concentrations of serum sirtuin 1, visfatin and IL-27 were assessed using ELISA. The T1DM and HD group had higher cIMT (p = 0.018) and lower left ventricular global longitudinal strain (p = 0.025) compared to females with T1DM exclusively. In women with a double diagnosis, the sirtuin 1 and IL-27 concentrations were non-significantly higher than in other groups and significantly positively correlated with each other (r = 0.445, p = 0.018) and thyroid volume (r = 0.511, p = 0.005; r = 0.482, p = 0.009, respectively) and negatively correlated with relative wall thickness (r = –0.451, p = 0.016; r = –0.387, p = 0.041, respectively). These relationships were not observed in the control group nor for the visfatin concentration. These results suggest that sirtuin 1 and IL-27 contribute to the pathogenesis of early cardiac dysfunction in women with T1DM and HD.
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28
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Gubitosi-Klug R, Gao X, Pop-Busui R, de Boer IH, White N, Aiello LP, Miller R, Palmer J, Tamborlane W, Wallia A, Kosiborod M, Lachin JM, Bebu I. Associations of Microvascular Complications With the Risk of Cardiovascular Disease in Type 1 Diabetes. Diabetes Care 2021; 44:1499-1505. [PMID: 33980605 PMCID: PMC8323173 DOI: 10.2337/dc20-3104] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/26/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We examined whether the presence of microvascular complications was associated with increased subsequent risk of cardiovascular disease (CVD) among participants with type 1 diabetes in the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study followed for >35 years. RESEARCH DESIGN AND METHODS Standardized longitudinal data collection included: 1) stereoscopic seven-field retinal fundus photography centrally graded for retinopathy stage and clinically significant macular edema; 2) urinary albumin excretion rate (AER) and estimated glomerular filtration rate (eGFR); 3) cardiovascular autonomic neuropathy (CAN) reflex testing; and 4) adjudicated CVD events, including death from CVD, nonfatal myocardial infarction, stroke, subclinical myocardial infarction on electrocardiogram, confirmed angina, or coronary artery revascularization. Cox proportional hazards models assessed the association of microvascular complications with subsequent risk of CVD. RESULTS A total of 239 participants developed CVD, including 120 participants who suffered major adverse cardiovascular events (MACE) defined as nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. The presence of microvascular disease (diabetic retinopathy, kidney disease, or CAN) was associated with increased risk of subsequent CVD and MACE (hazard ratios 1.86 to 3.18 and 2.09 to 3.63, respectively), associations that remained significant after adjusting for age and HbA1c. After adjustment for traditional CVD risk factors, however, only sustained AER ≥30 mg/24 h occurring alone and/or with eGFR <60 mL/min/1.73 m2 and the presence of both retinal and kidney disease remained associated with CVD. CONCLUSIONS Advanced microvascular disease, especially moderate to severe albuminuria or eGFR <60 mL/min/1.73 m2, conveyed an increased risk of subsequent cardiovascular disease in the DCCT/EDIC cohort.
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Affiliation(s)
- Rose Gubitosi-Klug
- Pediatric Endocrinology, UH Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Xiaoyu Gao
- Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Ian H de Boer
- Division of Nephrology, University of Washington, Seattle, WA
| | - Neill White
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Ryan Miller
- Division of Pediatric Endocrinology, University of Maryland, Baltimore, MD
| | - Jerry Palmer
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA
| | - William Tamborlane
- Department of Pediatrics and Endocrinology, Yale School of Medicine, New Haven, CT
| | - Amisha Wallia
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - John M Lachin
- Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Ionut Bebu
- Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Rockville, MD
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29
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Keshavarzi S, Braffett BH, Pop-Busui R, Orchard TJ, Soliman EZ, Lorenzi GM, Barnie A, Karger AB, Gubitosi-Klug RA, Dagogo-Jack S, Paterson AD. Risk Factors for Longitudinal Resting Heart Rate and Its Associations With Cardiovascular Outcomes in the DCCT/EDIC Study. Diabetes Care 2021; 44:1125-1132. [PMID: 33632724 PMCID: PMC8132325 DOI: 10.2337/dc20-2387] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/28/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Individuals with diabetes have higher resting heart rate compared with those without, which may be predictive of long-term cardiovascular disease (CVD) risk. Using data from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study, we evaluated whether the beneficial effect of intensive versus conventional diabetes therapy on heart rate persisted, the factors mediating the differences in heart rate between treatment groups, and the effects of heart rate on future CVD risk. RESEARCH DESIGN AND METHODS Longitudinal changes in heart rate, from annual electrocardiograms over 22 years of EDIC follow-up, were evaluated in 1,402 participants with type 1 diabetes. Linear mixed models were used to assess the effect of DCCT treatment group on mean heart rate over time, and Cox proportional hazards models were used to estimate the effect of heart rate on CVD risk during DCCT/EDIC. RESULTS At DCCT closeout, 52% of participants were male and mean ± SD age was 33 ± 7 years, diabetes duration 12 ± 5 years, and HbA1c 7.4 ± 1.2% (intensive) and 9.1 ± 1.6% (conventional). Through EDIC, participants in the intensive group had significantly lower heart rate in comparison with the conventional group. While significant group differences in heart rate were fully attenuated by DCCT/EDIC mean HbA1c, higher heart rate predicted CVD and major adverse cardiovascular events independent of other risk factors. CONCLUSIONS After 22 years of follow-up, former intensive versus conventional therapy remained significantly associated with lower heart rate, consistent with the long-term beneficial effects of intensive therapy on CVD. DCCT treatment group effects on heart rate were explained by differences in DCCT/EDIC mean HbA1c.
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Affiliation(s)
| | - Barbara H Braffett
- The Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | | | | | | | | | | | | | - Rose A Gubitosi-Klug
- Case Western Reserve University and University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
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30
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Hansen CS, Jørgensen ME, Malik M, Witte DR, Brunner EJ, Tabák AG, Kivimäki M, Vistisen D. Heart Rate and Heart Rate Variability Changes Are Not Related to Future Cardiovascular Disease and Death in People With and Without Dysglycemia: A Downfall of Risk Markers? The Whitehall II Cohort Study. Diabetes Care 2021; 44:1012-1019. [PMID: 33526428 PMCID: PMC7985416 DOI: 10.2337/dc20-2490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/27/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Higher resting heart rate (rHR) and lower heart rate variability (HRV) are associated with increased risk of cardiovascular disease (CVD) and all-cause mortality in people with and without diabetes. It is unknown whether temporal changes in rHR and HRV may contribute to this risk. We investigated associations between 5-year changes in rHR and HRV and risk of future CVD and death, taking into account participants' baseline glycemic state. RESEARCH DESIGN AND METHODS In this prospective, population-based cohort study we investigated 4,611 CVD-free civil servants (mean [SD] age, 60 [5.9] years; 70% men). We measured rHR and/or six indices of HRV. Associations of 5-year change in 5-min rHR and HRV with fatal and nonfatal CVD and all-cause mortality or the composite of the two were assessed, with adjustments made for relevant confounders. Effect modification by glycemic state was tested. RESULTS At baseline, 63% of participants were normoglycemic, 29% had prediabetes, and 8% had diabetes. During a median (interquartile range) follow-up of 11.9 (11.4; 12.3) years, 298 participants (6.5%) experienced a CVD event and 279 (6.1%) died of non-CVD-related causes. We found no association between 5-year changes in rHR and HRV and future events. Only baseline rHR was associated with all-cause mortality. A 10 bpm-higher baseline HR level was associated with an 11.4% higher rate of all-cause mortality (95% CI 1.0-22.9%; P = 0.032). Glycemic state did not modify associations. CONCLUSIONS Changes in rHR and HRV and possibly also baseline values of these measures are not associated with future CVD or death in people with or without dysglycemia.
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Affiliation(s)
- Christian S Hansen
- Steno Diabetes Center Copenhagen, Gentofte, Denmark .,National Institute of Public Health, Southern Denmark University, Odense, Denmark
| | | | - Marek Malik
- National Heart and Lung Institute, Imperial College, London, U.K.,Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Daniel R Witte
- National Institute of Public Health, Southern Denmark University, Odense, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark.,Danish Diabetes Academy, Odense, Denmark.,Steno Diabetes Center Aarhus, Aarhus, Denmark
| | - Eric J Brunner
- Department of Epidemiology and Public Health, University College London, London, U.K
| | - Adam G Tabák
- Department of Epidemiology and Public Health, University College London, London, U.K.,Department of Internal Medicine and Oncology, Semmelweis University Faculty of Medicine, Budapest, Hungary.,Department of Public Health, Semmelweis University Faculty of Medicine, Budapest, Hungary
| | - Mika Kivimäki
- Department of Epidemiology and Public Health, University College London, London, U.K
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31
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Jensen TS, Karlsson P, Gylfadottir SS, Andersen ST, Bennett DL, Tankisi H, Finnerup NB, Terkelsen AJ, Khan K, Themistocleous AC, Kristensen AG, Itani M, Sindrup SH, Andersen H, Charles M, Feldman EL, Callaghan BC. Painful and non-painful diabetic neuropathy, diagnostic challenges and implications for future management. Brain 2021; 144:1632-1645. [PMID: 33711103 DOI: 10.1093/brain/awab079] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 12/12/2022] Open
Abstract
Peripheral neuropathy is one of the most common complications of both type 1 and type 2 diabetes. Up to half of patients with diabetes develop neuropathy during the course of their disease, which is accompanied by neuropathic pain in 30-40% of cases. Peripheral nerve injury in diabetes can manifest as progressive distal symmetric polyneuropathy, autonomic neuropathy, radiculo-plexopathies, and mononeuropathies. The most common diabetic neuropathy is distal symmetric polyneuropathy, which we will refer to as DN, with its characteristic glove and stocking like presentation of distal sensory or motor function loss. DN or its painful counterpart, painful DN, are associated with increased mortality and morbidity; thus, early recognition and preventive measures are essential. Nevertheless, it is not easy to diagnose DN or painful DN, particularly in patients with early and mild neuropathy, and there is currently no single established diagnostic gold standard. The most common diagnostic approach in research is a hierarchical system, which combines symptoms, signs, and a series of confirmatory tests. The general lack of long-term prospective studies has limited the evaluation of the sensitivity and specificity of new morphometric and neurophysiological techniques. Thus, the best paradigm for screening DN and painful DN both in research and in clinical practice remains uncertain. Herein, we review the diagnostic challenges from both clinical and research perspectives and their implications for managing patients with DN. There is no established DN treatment, apart from improved glycaemic control, which is more effective in type 1 than in type 2 diabetes, and only symptomatic management is available for painful DN. Currently, less than one-third of patients with painful DN derive sufficient pain relief with existing pharmacotherapies. A more precise and distinct sensory profile from patients with DN and painful DN may help identify responsive patients to one treatment versus another. Detailed sensory profiles will lead to tailored treatment for patient subgroups with painful DN by matching to novel or established DN pathomechanisms and also for improved clinical trials stratification. Large randomized clinical trials are needed to identify the interventions, i.e. pharmacological, physical, cognitive, educational, etc., which lead to the best therapeutic outcomes.
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Affiliation(s)
- Troels S Jensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Pall Karlsson
- Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Sandra S Gylfadottir
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Signe T Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Department of Public Health, Aarhus University, Aarhus, Denmark
| | - David L Bennett
- Nuffield Department of Clinical Neuroscience, Oxford University, Oxford, UK
| | - Hatice Tankisi
- Department of Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Astrid J Terkelsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Karolina Khan
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Mustapha Itani
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Søren H Sindrup
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Charles
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
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32
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Lim S, Bae JH, Kwon HS, Nauck MA. Reply to: Autonomic dyshomeostasis in patients with diabetes mellitus during COVID-19. Nat Rev Endocrinol 2021; 17:189-190. [PMID: 33462400 PMCID: PMC7812329 DOI: 10.1038/s41574-021-00467-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Jae Hyun Bae
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hyuk-Sang Kwon
- Department of Internal Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Michael A Nauck
- Diabetes Division, Katholisches Klinikum Bochum, St Josef- Hospital (Ruhr- Universität Bochum), Bochum, Germany
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Dhumad MM, Hamdan FB, Khudhair MS, Al-Matubsi HY. Correlation of staging and risk factors with cardiovascular autonomic neuropathy in patients with type II diabetes mellitus. Sci Rep 2021; 11:3576. [PMID: 33574349 PMCID: PMC7878737 DOI: 10.1038/s41598-021-80962-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 12/29/2020] [Indexed: 12/26/2022] Open
Abstract
The impairment of cardiovascular autonomic control among the underdiagnosed complication of diabetes mellitus (DM) with a high prevalence rate of up to 60% in type 2 DM (T2DM). Cardiac autonomic neuropathy (CAN) is an independent risk factor for cardiovascular mortality, arrhythmia, silent ischemia, any major cardiovascular event, and heart failure. We aimed to evaluate cardiovascular autonomic activity by different physiological maneuvers, study risk factors for diabetic CAN including age, gender, duration of diabetes, body mass index (BMI), and glycemic control, and correlate CAN stage with risk factors. One hundred and forty-two T2DM patients consisted of 62 males and 80 females and 100 volunteers as a control sample. Cardiac autonomic functions were assessed by Ewing's tests. Glycated hemoglobin (HbA1c), body weight, height, body mass index (BMI), and waist-hip ratio (WHR) were also measured. Cardiovascular autonomic functions and Ewing scores were significantly different in people with diabetes when compared with control healthy subjects. Ewings test values and Ewing scores were significantly different between diabetics with and without CAN and within patients with different CAN staging. People with diabetes with CAN have a significantly longer duration of disease when compared to those without CAN. A strong association has been found between CAN severity and patient age, duration of disease, HbA1c severity, and the WHR (P < 0.001) but not with BMI. The duration of disease and HbA1c level appear to be associated with the development of CAN (P = 0.001 and P = 0.008, respectively). The poorer glycemic control and the longer the duration of the disease, the higher the prevalence of CAN in T2DM. Age, duration of disease, WHR, and HbA1c are well correlated with the severity of CAN. Parasympathetic impairment is more sensitive to the detection of autonomic dysfunctions than do sympathetic impairment.
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Affiliation(s)
- Muhanad M Dhumad
- Section of Pharmacy, Baghdad College of Medical Sciences, Baghdad, Iraq
| | - Farqad B Hamdan
- Department of Physiology, College of Medicine, Al-Nahrain University, Baghdad, Iraq
| | - Mahmood S Khudhair
- Endocrinology Section, Department of Medicine, College of Medicine, Al-Nahrain University, Baghdad, Iraq
| | - Hisham Y Al-Matubsi
- Department of Pharmacology and Medical Sciences, University of Petra, Amman, Jordan.
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Tang Y, Shah H, Bueno Junior CR, Sun X, Mitri J, Sambataro M, Sambado L, Gerstein HC, Fonseca V, Doria A, Pop-Busui R. Intensive Risk Factor Management and Cardiovascular Autonomic Neuropathy in Type 2 Diabetes: The ACCORD Trial. Diabetes Care 2021; 44:164-173. [PMID: 33144354 PMCID: PMC7783932 DOI: 10.2337/dc20-1842] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The effects of preventive interventions on cardiovascular autonomic neuropathy (CAN) remain unclear. We examined the effect of intensively treating traditional risk factors for CAN, including hyperglycemia, hypertension, and dyslipidemia, in individuals with type 2 diabetes (T2D) and high cardiovascular risk participating in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. RESEARCH DESIGN AND METHODS CAN was defined as heart rate variability indices below the fifth percentile of the normal distribution. Of 10,251 ACCORD participants, 71% (n = 7,275) had a CAN evaluation at study entry and at least once after randomization. The effects of intensive interventions on CAN were analyzed among these subjects through generalized linear mixed models. RESULTS As compared with standard intervention, intensive glucose treatment reduced CAN risk by 16% (odds ratio [OR] 0.84, 95% CI 0.75-0.94, P = 0.003)-an effect driven by individuals without cardiovascular disease (CVD) at baseline (OR 0.73, 95% CI 0.63-0.85, P < 0.0001) rather than those with CVD (OR 1.10, 95% CI 0.91-1.34, P = 0.34) (P interaction = 0.001). Intensive blood pressure (BP) intervention decreased CAN risk by 25% (OR 0.75, 95% CI 0.63-0.89, P = 0.001), especially in patients ≥65 years old (OR 0.66, 95% CI 0.49-0.88, P = 0.005) (P interaction = 0.05). Fenofibrate did not have a significant effect on CAN (OR 0.91, 95% CI 0.78-1.07, P = 0.26). CONCLUSIONS These data confirm a beneficial effect of intensive glycemic therapy and demonstrate, for the first time, a similar benefit of intensive BP control on CAN in T2D. A negative CVD history identifies T2D patients who especially benefit from intensive glycemic control for CAN prevention.
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Affiliation(s)
- Yaling Tang
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Hetal Shah
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | | | - Xiuqin Sun
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Endocrinology and Metabolism, Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Joanna Mitri
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Maria Sambataro
- Endocrine, Metabolism and Nutrition Disease Unit, Internal Medicine Department, Santa Maria of Ca' Foncello Hospital, Treviso, Italy
| | - Luisa Sambado
- Endocrine, Metabolism and Nutrition Disease Unit, Internal Medicine Department, Santa Maria of Ca' Foncello Hospital, Treviso, Italy
| | - Hertzel C Gerstein
- McMaster University and the Population Health Research Institute, Hamilton, Ontario, Canada
| | - Vivian Fonseca
- Section of Endocrinology, Tulane University Health Sciences Center, New Orleans, LA
| | - Alessandro Doria
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Hansen GM, Jørgensen PG, Andersen HU, Rossing P, Jensen MT. Relationship between peripheral neuropathy, diastolic function and adverse cardiovascular outcome in individuals with type 1 diabetes mellitus without known cardiovascular disease: Results from the Thousand & 1 Study. Diabetes Obes Metab 2021; 23:158-165. [PMID: 32991054 DOI: 10.1111/dom.14209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 09/09/2020] [Accepted: 09/25/2020] [Indexed: 12/16/2022]
Abstract
AIMS To investigate the association between measures of peripheral neuropathy (PN) and impaired left ventricular diastolic function, and the prognosis in patients with type 1 diabetes (T1DM) and no known cardiovascular disease (CVD), and to test the incremental prognostic value of including measures of PN and diastolic function to the established Steno T1 Risk Engine. METHODS Echocardiography and quantitative biothesiometry was performed to evaluate diastolic function and PN. The participants were categorized according to severity of diastolic function and PN. The study endpoint was combined cardiovascular (CV) events and all-cause death. Associations were analysed using multivariable regression models. The prognostic capability was assessed with Harrell's C-statistics and tested against the Steno T1 Risk Engine. RESULTS A total of 946 individuals (51.5% men) were included. The mean (SD) follow-up was 6 (1.3) years. The total number of CV events and all-cause death were 100. In the multi-adjusted analysis, both PN and impaired diastolic function were associated with increased risk of CV events and all-cause death: severe PN versus no PN: hazard ratio (HR) 2.23 (95% confidence interval [CI] 1.06-4.68; P = 0.035); severe diastolic impairment versus normal function: HR 2.27 (95% CI 1.16-4.44; P = 0.016). Measures of diastolic function improved prognostic capability when added to the Steno T1 Risk Engine: C-statistic 0.797 (95% CI 0.793-0.817) versus 0.785 (95% CI 0.744-0.825; P = 0.006). CONCLUSION Peripheral neuropathy and impaired diastolic function are associated with an increased risk of CV events and all-cause death in patients with T1DM. Measures of diastolic function improved prediction of prognosis by the Steno T1 Risk Engine.
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Affiliation(s)
- Gorm Mørk Hansen
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Godsk Jørgensen
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | | | - Magnus Thorsten Jensen
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Cardiology, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Decreased glomerular filtration rate and increased albuminuria for identification of cardiovascular autonomic neuropathy in subjects with and without diabetes. Auton Neurosci 2020; 230:102757. [PMID: 33316751 DOI: 10.1016/j.autneu.2020.102757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 02/21/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the relationship between chronic kidney disease (CKD) and cardiovascular autonomic neuropathy (CAN). RESEARCH DESIGN AND METHODS From October 2008 to May 2011, we enrolled 218 patients with diabetes and 62 nondiabetic subjects. Heart rate variability was represented as the maximal heart rate minus the minimal heart rate (HRmax-min) during a one-minute deep breathing test. Normal, impaired cardiovascular autonomic function and CAN were defined as s HRmax-min > 15 beats/min, HRmax-min of 10-15 beats/min and HRmax-min < 10 beats/min, respectively. CKD was diagnosed if the estimated glomerular filtration rate (eGFR) was <60/min/1.73 m2 or albuminuria. RESULTS In our sample, 19.4% of nondiabetic subjects and 49.5% of diabetic subjects had CKD. The prevalence of CAN was higher among patients with diabetes than among nondiabetic subjects (26.4 vs. 4.9%). A significant association was observed between eGFR and HRmax-min. CAN was independently associated with CKD with an adjusted odds ratio of 2.77 (95% CI, 1.15-6.68) in diabetic patients. A positive linear trend was observed for the odds of CAN with increasing CKD severity in diabetes. The areas under the curve (AUCs) for the predictive ability of eGFR for the risk of impaired cardiovascular autonomic function for nondiabetic group and CAN for the diabetic group were 0.734 and 0.703, respectively. Adding age, sex, body mass index, and albuminuria to the prediction model increased the AUCs to 0.852 and 0.791, respectively. CONCLUSION CKD is associated with the risk of CAN in both nondiabetic and diabetic subjects. eGFR and albuminuria improve the prediction of CAN.
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Wegeberg AM, Lunde ED, Riahi S, Ejskjaer N, Drewes AM, Brock B, Pop-Busui R, Brock C. Cardiac vagal tone as a novel screening tool to recognize asymptomatic cardiovascular autonomic neuropathy: Aspects of utility in type 1 diabetes. Diabetes Res Clin Pract 2020; 170:108517. [PMID: 33096186 DOI: 10.1016/j.diabres.2020.108517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/25/2022]
Abstract
AIMS To test the performance of the cardiac vagal tone (CVT) derived from a 5-minute ECG recording compared with the standardized cardiovascular autonomic reflex tests (CARTs). METHODS Cross-sectional study included 56 well-phenotyped adults with type 1 diabetes (19-71 years, 2-54 years disease-duration). Autonomic testing included: standardized CARTs obtained with the VAGUS™, CVT, and indices of heart rate variability (HRV) obtained at 24- and 120-hour, and electrochemical skin conductance assessed with SUDOSCAN®. ROC AUC and cut-off values were calculated for CVT to recognize CAN based on ≥ 2 (established CAN, n = 7) or 1 (borderline CAN, n = 9) abnormal CARTs and compared to HRV indices and electrochemical skin conductance. RESULTS Established CAN: The cut-off CVT value of 3.2LVS showed 67% sensitivity and 87% specificity (p = 0.01). Indices of HRV at either 24-hour (AUC > 0.90) and 120-hour (AUC > 0.88) performed better than CVT. Borderline CAN: The cut-off CVT value of 5.2LVS indicated 88% sensitivity and 63% specificity (p = 0.07). CVT performed better than HRV indices (AUC < 0.72). Electrochemical skin conductance (AUC:0.63-0.72) had lower sensitivity and specificity compared with CVT. CONCLUSIONS Implementation of CVT with a clinically applicable cut-off value may be considered a quicker and accessible screening tool which could ultimately decrease the number of unrecognized CAN and initiate earlier prevention initiatives.
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Affiliation(s)
- Anne-Marie Wegeberg
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Elin D Lunde
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Sam Riahi
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark; Steno Diabetes Center North Denmark, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark
| | | | - Rodica Pop-Busui
- Department of Internal Medicine, Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, USA
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark; Steno Diabetes Center North Denmark, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark.
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Lin YK, Fisher SJ, Pop‐Busui R. Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies. J Diabetes Investig 2020; 11:1388-1402. [PMID: 32403204 PMCID: PMC7610104 DOI: 10.1111/jdi.13290] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022] Open
Abstract
Impaired awareness of hypoglycemia (IAH) is a reduction in the ability to recognize low blood glucose levels that would otherwise prompt an appropriate corrective therapy. Identified in approximately 25% of patients with type 1 diabetes, IAH has complex pathophysiology, and might lead to serious and potentially lethal consequences in patients with diabetes, particularly in those with more advanced disease and comorbidities. Continuous glucose monitoring systems can provide real-time glucose information and generate timely alerts on rapidly falling or low blood glucose levels. Given their improvements in accuracy, affordability and integration with insulin pump technology, continuous glucose monitoring systems are emerging as critical tools to help prevent serious hypoglycemia and mitigate its consequences in patients with diabetes. This review discusses the current knowledge on IAH and effective diagnostic methods, the relationship between hypoglycemia and cardiovascular autonomic neuropathy, a practical approach to evaluating cardiovascular autonomic neuropathy for clinicians, and recent evidence from clinical trials assessing the effects of the use of CGM technologies in patients with type 1 diabetes with IAH.
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Affiliation(s)
- Yu Kuei Lin
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Simon J Fisher
- Division of Endocrinology, Metabolism and DiabetesDepartment of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Rodica Pop‐Busui
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Agochukwu-Mmonu N, Pop-Busui R, Wessells H, Sarma AV. Autonomic neuropathy and urologic complications in diabetes. Auton Neurosci 2020; 229:102736. [PMID: 33197694 DOI: 10.1016/j.autneu.2020.102736] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/21/2020] [Accepted: 10/05/2020] [Indexed: 12/31/2022]
Abstract
Diabetic autonomic neuropathy affects the entire autonomic nervous system and can lead to dysfunction of the cardiovascular, gastrointestinal, and genitourinary organ systems. Genitourinary dysfunction associated with diabetic autonomic neuropathy includes diabetic bladder dysfunction, sexual dysfunction, and recurrent urinary tract infections. Urological complications in diabetes mellitus are very common; in fact, genitourinary complications are more common than diabetic neuropathy or nephropathy. While several studies have reported on genitourinary dysfunction in individuals with diabetes, UroEDIC, an ancillary study to the Diabetes Control and Complications Trial (DCCT) and its observational follow up, the Epidemiology of Diabetes Interventions and Complications study (EDIC), comprehensively characterized the association between urologic complications and cardiovascular autonomic neuropathy. UroEDIC demonstrated significant associations between autonomic neuropathy and urologic complications in type 1 diabetes, specifically erectile dysfunction, female sexual dysfunction, and lower urinary tract symptoms. In this narrative review, we review the current literature on urological complications in diabetes.
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Affiliation(s)
| | - Rodica Pop-Busui
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Hunter Wessells
- Department of Urology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Aruna V Sarma
- Department of Urology, University of Michigan, Ann Arbor, MI, United States of America
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40
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Bebu I, Braffett BH, Schade D, Sivitz W, Malone JI, Pop-Busui R, Lorenzi GM, Lee P, Trapani VR, Wallia A, Herman WH, Lachin JM. An Observational Study of the Equivalence of Age and Duration of Diabetes to Glycemic Control Relative to the Risk of Complications in the Combined Cohorts of the DCCT/EDIC Study. Diabetes Care 2020; 43:2478-2484. [PMID: 32788280 PMCID: PMC7510046 DOI: 10.2337/dc20-0226] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/13/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This epidemiological analysis of the pooled Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) cohort describes the equivalence of a 1-percentage point increase in HbA1c (such as from 7% to 8%) and years of additional age or duration of type 1 diabetes (T1D) relative to the risk of complications. RESEARCH DESIGN AND METHODS Separate Cox proportional hazards models determined the number of additional years of age and/or duration of T1D that would result in the same increase in risk of microvascular (retinopathy, nephropathy, and neuropathy) and cardiovascular complications and mortality as a 1-percentage point increase in HbA1c. RESULTS The risk of any cardiovascular disease associated with a 1-percentage point increase in HbA1c was equivalent to the risk associated with 4.3 (95% CI 2.7-5.9) additional years of age or 5.6 (95% CI 2.7-6.5) additional years' duration of T1D. The risk of estimated glomerular filtration rate <60 mL/min/1.73 m2 and/or end-stage renal disease associated with a 1-percentage point increase in HbA1c was equivalent to the risk associated with 12.1 (95% CI 8.3-15.9) additional years of age or 18.0 (95% CI 4.3-31.7) additional years' duration of T1D. The proliferative diabetic retinopathy risk associated with a 1-percentage point increase in HbA1c was equivalent to the risk associated with 6.4 (95% CI 5.3-7.4) additional years' duration of T1D, while for mortality risk, it was equivalent to the risk associated with 12.9 (95% CI 6.6-19.3) additional years of age. CONCLUSIONS Our results help evaluate the impact of glycemia on advanced complications in a way that may be more interpretable to health care providers and individuals with T1D.
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Affiliation(s)
- Ionut Bebu
- Biostatistics Center, The George Washington University, Rockville, MD
| | | | | | | | | | | | | | - Pearl Lee
- University of Michigan, Ann Arbor, MI
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Braffett BH, Gubitosi-Klug RA, Albers JW, Feldman EL, Martin CL, White NH, Orchard TJ, Lopes-Virella M, Lachin JM, Pop-Busui R. Risk Factors for Diabetic Peripheral Neuropathy and Cardiovascular Autonomic Neuropathy in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study. Diabetes 2020; 69:1000-1010. [PMID: 32051148 PMCID: PMC7171957 DOI: 10.2337/db19-1046] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022]
Abstract
The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study demonstrated that intensive glucose control reduced the risk of developing diabetic peripheral neuropathy (DPN) and cardiovascular autonomic neuropathy (CAN). We evaluated multiple risk factors and phenotypes associated with DPN and CAN in this large, well-characterized cohort of participants with type 1 diabetes, followed for >23 years. DPN was defined by symptoms, signs, and nerve conduction study abnormalities in ≥2 nerves; CAN was assessed using standardized cardiovascular reflex tests. Generalized estimating equation models assessed the association of DPN and CAN with individual risk factors measured repeatedly. During DCCT/EDIC, 33% of participants developed DPN and 44% CAN. Higher mean HbA1c was the most significant risk factor for DPN, followed by older age, longer duration, greater height, macroalbuminuria, higher mean pulse rate, β-blocker use, and sustained albuminuria. The most significant risk factor for CAN was older age, followed by higher mean HbA1c, sustained albuminuria, longer duration of type 1 diabetes, higher mean pulse rate, higher mean systolic blood pressure, β-blocker use, estimated glomerular filtration rate <60 mL/min/1.73 m2, higher most recent pulse rate, and cigarette smoking. These findings identify risk factors and phenotypes of participants with diabetic neuropathy that can be used in the design of new interventional trials and for personalized approaches to neuropathy prevention.
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Affiliation(s)
| | - Rose A Gubitosi-Klug
- Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH
| | | | - Eva L Feldman
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Neil H White
- Washington University School of Medicine in St. Louis, St Louis, MO
| | - Trevor J Orchard
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Maria Lopes-Virella
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - John M Lachin
- Biostatistics Center, George Washington University, Rockville, MD
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Ang L, Dillon B, Mizokami-Stout K, Pop-Busui R. Cardiovascular autonomic neuropathy: A silent killer with long reach. Auton Neurosci 2020; 225:102646. [PMID: 32106052 DOI: 10.1016/j.autneu.2020.102646] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/30/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
Cardiovascular autonomic neuropathy (CAN) is a common and deadly complication of diabetes mellitus, which is frequently overlooked in clinical practice due to its characteristic subtle presentation earlier in disease. Yet, timely detection of CAN may help implementation of tailored interventions to prevent its progression and mitigate the risk of associated complications, including cardiovascular disease (CVD), cardiac arrhythmias, myocardial dysfunction leading to congestive heart failure and all-cause mortality. This review highlights current CAN epidemiology trends, novel mechanisms linking CAN with other diabetes complications and current recommendations for diagnosis and management of the disease in the clinical setting.
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Affiliation(s)
- Lynn Ang
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Brendan Dillon
- University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America.
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Bencsik P, Gömöri K, Szabados T, Sántha P, Helyes Z, Jancsó G, Ferdinandy P, Görbe A. Myocardial ischaemia reperfusion injury and cardioprotection in the presence of sensory neuropathy: Therapeutic options. Br J Pharmacol 2020; 177:5336-5356. [PMID: 32059259 PMCID: PMC7680004 DOI: 10.1111/bph.15021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 12/12/2022] Open
Abstract
During the last decades, mortality from acute myocardial infarction has been dramatically reduced. However, the incidence of post‐infarction heart failure is still increasing. Cardioprotection by ischaemic conditioning had been discovered more than three decades ago. Its clinical translation, however, is still an unmet need. This is mainly due to the disrupted cardioprotective signalling pathways in the presence of different cardiovascular risk factors, co‐morbidities and the medication being taken. Sensory neuropathy is one of the co‐morbidities that has been shown to interfere with cardioprotection. In the present review, we summarize the diverse aetiology of sensory neuropathies and the mechanisms by which these neuropathies may interfere with ischaemic heart disease and cardioprotective signalling. Finally, we suggest future therapeutic options targeting both ischaemic heart and sensory neuropathy simultaneously. LINKED ARTICLES This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.23/issuetoc
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Affiliation(s)
- Péter Bencsik
- Cardiovascular Research Group, Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary.,Pharmahungary Group, Szeged, Hungary
| | - Kamilla Gömöri
- Cardiovascular Research Group, Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary.,Pharmahungary Group, Szeged, Hungary
| | - Tamara Szabados
- Cardiovascular Research Group, Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary.,Pharmahungary Group, Szeged, Hungary
| | - Péter Sántha
- Department of Physiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Pécs, Hungary.,Molecular Pharmacology Research Group, Centre for Neuroscience, János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Gábor Jancsó
- Department of Physiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Péter Ferdinandy
- Pharmahungary Group, Szeged, Hungary.,Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Anikó Görbe
- Cardiovascular Research Group, Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Szeged, Hungary.,Pharmahungary Group, Szeged, Hungary.,Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
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Ju J, Tomaszewski EL, Orchard TJ, Evans RW, Feingold E, Costacou T. The haptoglobin 2-2 genotype is associated with cardiac autonomic neuropathy in type 1 diabetes: the RETRO HDLc study. Acta Diabetol 2020; 57:271-278. [PMID: 31529337 PMCID: PMC7054154 DOI: 10.1007/s00592-019-01422-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
AIM The haptoglobin (Hp) 2-2 genotype has been shown to increase the risk of coronary artery disease, kidney dysfunction and mortality from cardiovascular and renal causes in type 1 diabetes (T1D). Similar associations, however, have not been observed in those without diabetes. As cardiac autonomic neuropathy (CAN) is a cardiovascular disease risk factor, we assessed the presence of an association between the Hp 2-2 genotype and CAN. METHODS The study included 216 individuals with childhood-onset T1D and 200 individuals with normal glucose tolerance (NGT) of similar age and gender distribution to their counterparts with T1D. CAN was assessed using an electrocardiogram as an abnormal, age-specific, heart rate response to deep breathing. Multivariable logistic regression models were used to assess the association between the Hp 2-2 genotype and CAN. RESULTS Compared with NGT, participants with T1D had a similar proportion of Hp 2-2 carriers (41.5% vs. 32.0%, p = 0.05) but a greater CAN prevalence (28.2% vs. 5.0%, p < 0.0001). In multivariable logistic regression models, those carrying the Hp 2-2 genotype had significantly higher odds of CAN compared with Hp 1-1 or Hp 2-1 carriers (OR = 2.27, p = 0.01). The presence of T1D (OR = 4.20, p = 0.0003), hypertension (OR = 2.08, p = 0.03), eGFR (OR = 0.98, p = 0.01) and WBC count (OR = 1.21, p = 0.02) were also associated with CAN. There was no T1D by Hp interaction (p = 0.92), although in stratified analyses, the Hp-CAN association was significant only in T1D. CONCLUSIONS The Hp 2-2 genotype was independently associated with greater odds of CAN in T1D though no definitive conclusions could be made in NGT.
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Affiliation(s)
- Jinghui Ju
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Erin L Tomaszewski
- Diabetes and Lipid Research Clinic, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 3512 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Trevor J Orchard
- Diabetes and Lipid Research Clinic, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 3512 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Rhobert W Evans
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Eleanor Feingold
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Tina Costacou
- Diabetes and Lipid Research Clinic, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 3512 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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Poliwczak AR, Białkowska J, Woźny J, Koziróg M, Bała A, Jabłkowski M. Cardiovascular risk assessment by electrocardiographic Holter monitoring in patients with chronic hepatitis C. Arch Med Sci 2020; 16:1031-1039. [PMID: 32863991 PMCID: PMC7444696 DOI: 10.5114/aoms.2020.96600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/05/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cardiovascular diseases are ranked as the third cause of mortality among people infected with hepatitis C virus (HCV), but the relationship of infection with cardiovascular risk remains disputable. We have focused on the comprehensive use of parameters obtainable during long-term electrocardiographic (ECG) Holter monitoring. MATERIAL AND METHODS Heart rate variability and turbulence (HRV and HRT), deceleration/acceleration capacity (DC/AC), corrected QT interval (QTc) and late potential (LP) were used. 36 persons were included, and 30 healthy subjects formed a control group. All were submitted to 24-hour Holter ECG-monitoring. RESULTS The studied groups were not statistically significantly different with regards to basic anthropometric parameters. Statistically significantly higher medium and maximum heart rhythm and aminotransferase activities were recorded in patients with hepatitis C. The HRV parameters r-MSSD, p50NN, HF, and absolute DC/AC values were significantly lower in the subjects with hepatitis C than those in the control group. The QTc interval, measured for nocturnal hours, was also significantly longer in that group. There were no differences in the albumin level or basic echocardiographic parameters, including left ventricle ejection fraction. Nor was there any difference in the HRT parameters, or LP. The most interesting observation was the positive correlation among the number of viral RNA copies and DC, and LF. CONCLUSIONS We confirmed the presence of autonomic disorders with prevalence of sympathetic system activity and prolonged QTc interval in patients with chronic hepatitis C. Those parameters significantly correlated with infection intensity. Our results suggest that HCV infection could be an independent cardiovascular risk factor, not associated with the lipid profile. Further prospective studies are needed.
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Affiliation(s)
- Adam R. Poliwczak
- Department of Human Physiology, Medical University of Lodz, Lodz, Poland
| | - Jolanta Białkowska
- Department of Infectious and Liver Diseases, Medical University of Lodz, Lodz, Poland
| | - Joanna Woźny
- Department of Infectious and Liver Diseases, Medical University of Lodz, Lodz, Poland
| | - Marzena Koziróg
- Department of Internal Diseases and Cardiac Rehabilitation, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Bała
- Department of Internal Diseases and Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Maciej Jabłkowski
- Department of Infectious and Liver Diseases, Medical University of Lodz, Lodz, Poland
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Garofolo M, Gualdani E, Giannarelli R, Aragona M, Campi F, Lucchesi D, Daniele G, Miccoli R, Francesconi P, Del Prato S, Penno G. Microvascular complications burden (nephropathy, retinopathy and peripheral polyneuropathy) affects risk of major vascular events and all-cause mortality in type 1 diabetes: a 10-year follow-up study. Cardiovasc Diabetol 2019; 18:159. [PMID: 31733651 PMCID: PMC6858978 DOI: 10.1186/s12933-019-0961-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/01/2019] [Indexed: 02/07/2023] Open
Abstract
Background Microvascular complications (MC) have been claimed to increase the risk for cardiovascular disease in diabetic subjects. However, the effect of MC burden on the risk of major vascular outcomes and all-cause mortality in type 1 diabetes is still poorly explored. We evaluated the relationship between microvascular complications burden and incidence of major cardiovascular events and all-cause mortality in subjects with type 1 diabetes. Methods We recruited 774 participants with type 1 diabetes in a single-center observational study over a follow-up of 10.8 ± 2.5 years. Hazard ratios (HR) for cardiovascular outcomes and all-cause death associated with microvascular complications were determined by unadjusted and adjusted Cox regression analysis. Results Out of 774 individuals, 54.9% had no-MC, 32.3% 1 MC, 9.7% 2 MC and 3.1% 3 MC. A total of 54 deaths (7.0%) occurred. Death rate increased from no-MC 2.1% (Ref) to 1 MC 7.2% (HR 3.54 [95% CI 1.59–7.87]), 2 MC 14.7% (HR 6.41 [95% CI 2.65–15.49]) and 3 MC 66.7% (HR 41.73 [95% CI 18.42–94.57], p < 0.0001). After adjustments, HRs were: 1 MC 2.05 (95% CI 0.88–4.76), 2 MC 1.98 (95% CI 0.75–5.21), 3 MC 7.02 (95% CI 2.44–20.20, p = 0.002). Forty-nine subjects (6.7%) had at least one cardiovascular event, and cumulative incidence went from no-MC 2.2% (Ref) to 1 MC 5.0%; (HR 2.27 [95% CI 0.96–5.38]), 2 MC 26.8% (HR 12.88 [95% CI 5.82–28.50]) and 3 MC 40.9% (HR 29.34 [95% CI 11.59–74.25], p < 0.0001). Upon adjustments, HRs were: 1 MC 1.59 (95% CI 0.65–3.88), 2 MC 4.33 (95% CI 1.75–10.74), 3 MC 9.31 (95% CI 3.18–27.25, p < 0.0001). Thirty-five individuals (4.8%) had at least one coronary event, which cumulative incidence increased with MC burden (p < 0.0001). Conclusions In type 1 diabetes, microvascular complications burden increases in an independent dose-dependent manner the risk of major cardiovascular outcomes and all-cause mortality. The presence and number of microvascular complications should be considered in stratifying overall cardiovascular risk in type 1 diabetes.
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Affiliation(s)
- Monia Garofolo
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Elisa Gualdani
- Epidemiology Unit, Regional Health Agency (ARS) of Tuscany, Florence, Italy
| | - Rosa Giannarelli
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Michele Aragona
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Fabrizio Campi
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Daniela Lucchesi
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Giuseppe Daniele
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Roberto Miccoli
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
| | - Paolo Francesconi
- Epidemiology Unit, Regional Health Agency (ARS) of Tuscany, Florence, Italy
| | - Stefano Del Prato
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy.
| | - Giuseppe Penno
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124, Pisa, Italy
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Boegle AK, Narayanaswami P. Sense, sense‐ability, and all that Mokken jazz. Muscle Nerve 2019; 60:496-498. [DOI: 10.1002/mus.26685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Aimee K. Boegle
- Department of Neurology, Division of Neuromuscular Diseases Beth Israel Deaconess Medical Center Boston Massachusetts
- Harvard Medical School Boston Massachusetts
| | - Pushpa Narayanaswami
- Department of Neurology, Division of Neuromuscular Diseases Beth Israel Deaconess Medical Center Boston Massachusetts
- Harvard Medical School Boston Massachusetts
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Pan Q, Li Q, Deng W, Zhao D, Qi L, Huang W, Ma L, Li H, Li Y, Lyu X, Wang A, Yao H, Guo L, Xing X. Prevalence and Diagnosis of Diabetic Cardiovascular Autonomic Neuropathy in Beijing, China: A Retrospective Multicenter Clinical Study. Front Neurosci 2019; 13:1144. [PMID: 31708736 PMCID: PMC6823192 DOI: 10.3389/fnins.2019.01144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 10/10/2019] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular autonomic neuropathy (CAN) is a debilitating condition occurring among diabetic patients especially those with long duration of disease. Whereas incidences and treatment of CAN has been well described for Western populations, fewer studies have been conducted among the Chinese. This study, therefore, aimed to assess the prevalence of CAN among sampled Chinese diabetic patients. Accordingly, 2,048 participants with a history of type 1 diabetes mellitus (T1DM, 73) and type 2 diabetes mellitus (T2DM, 1975) were randomly sampled from 13 hospitals. Patients’ biodata were recorded, and autonomic nervous system function tests performed to aid in the preliminary diagnosis of CAN. The final CAN diagnosis was based on the Ewing’s test in which heart rate variation (HRV) values were evaluated through deep-breathing (DB), lying-to-standing (LS), and Valsalva (V) tests. Systolic blood pressure (SBP) variation values were also evaluated through LS. In the T1DM group, 61.6% patients were diagnosed with CAN and no differences were observed in the baseline and clinical data between this group and those without CAN (P > 0.05). In the T2DM group, 62.6% patients were diagnosed with CAN and statistically significant differences were found between the CAN and non- CAN group with regards to age, duration of diabetes, metformin treatment, retinopathy, and hypertension history (P < 0.05). The most common manifestations of CAN included weakness (28.6%), dizziness (23.4%), frequent urination (19.6%), upper body sweating (18.3%), and nocturia (15.9%). Additionally, duration of disease and age were independent risk factors for CAN in T1DM and T2DM, respectively. On diagnosis, a combination of the V test + LS test provided the highest sensitivity of detecting CAN among T1DM group (sensitivity = 97.6%, AUC = 0.887) while for T2DM category, DB test had the highest sensitivity (83.6%), and maximal AUC (0.856) was found with V test + DB test. The overall prevalence of diabetes with CAN in the study was up to 63%.
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Affiliation(s)
- Qi Pan
- Department of Endocrinology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Quanmin Li
- The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Wei Deng
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Dong Zhao
- Center for Endocrine Metabolism and Immune Diseases, Luhe Hospital, Capital Medical University, Beijing, China
| | - Lin Qi
- Department of Endocrinology, Beijing Yanhua Hospital, Beijing, China
| | - Wei Huang
- Department of Endocrinology, Beijing Haidian Hospital, Beijing, China
| | - Li Ma
- South Section, Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hongmei Li
- Department of Endocrinology, Emergency General Hospital, Beijing, China
| | - Yufeng Li
- Department of Endocrinology, Beijing Pinggu Hospital, Beijing, China
| | - Xiaofeng Lyu
- Department of Endocrinology, Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Aihong Wang
- PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Hebin Yao
- Department of Endocrinology, Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Lixin Guo
- Department of Endocrinology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Xiaoyan Xing
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
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Pongrac Barlovic D, Harjutsalo V, Groop PH. Response to Comment on Pongrac Barlovic et al. The Association of Severe Diabetic Retinopathy With Cardiovascular Outcomes in Long-standing Type 1 Diabetes: A Longitudinal Follow-up. Diabetes Care 2018;41:2487-2494. Diabetes Care 2019; 42:e49-e50. [PMID: 30787064 DOI: 10.2337/dci18-0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Drazenka Pongrac Barlovic
- University Medical Center Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Valma Harjutsalo
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.,Diabetes and Obesity, Research Programs Unit, University of Helsinki, Helsinki, Finland.,The Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland .,Abdominal Center Nephrology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.,Diabetes and Obesity, Research Programs Unit, University of Helsinki, Helsinki, Finland.,Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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50
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Spallone V. Update on the Impact, Diagnosis and Management of Cardiovascular Autonomic Neuropathy in Diabetes: What Is Defined, What Is New, and What Is Unmet. Diabetes Metab J 2019; 43:3-30. [PMID: 30793549 PMCID: PMC6387879 DOI: 10.4093/dmj.2018.0259] [Citation(s) in RCA: 140] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/01/2019] [Indexed: 12/15/2022] Open
Abstract
The burden of diabetic cardiovascular autonomic neuropathy (CAN) is expected to increase due to the diabetes epidemic and its early and widespread appearance. CAN has a definite prognostic role for mortality and cardiovascular morbidity. Putative mechanisms for this are tachycardia, QT interval prolongation, orthostatic hypotension, reverse dipping, and impaired heart rate variability, while emerging mechanisms like inflammation support the pervasiveness of autonomic dysfunction. Efforts to overcome CAN under-diagnosis are on the table: by promoting screening for symptoms and signs; by simplifying cardiovascular reflex tests; and by selecting the candidates for screening. CAN assessment allows for treatment of its manifestations, cardiovascular risk stratification, and tailoring therapeutic targets. Risk factors for CAN are mainly glycaemic control in type 1 diabetes mellitus (T1DM) and, in addition, hypertension, dyslipidaemia, and obesity in type 2 diabetes mellitus (T2DM), while preliminary data regard glycaemic variability, vitamin B12 and D changes, oxidative stress, inflammation, and genetic biomarkers. Glycaemic control prevents CAN in T1DM, whereas multifactorial intervention might be effective in T2DM. Lifestyle intervention improves autonomic function mostly in pre-diabetes. While there is no conclusive evidence for a disease-modifying therapy, treatment of CAN manifestations is available. The modulation of autonomic function by SGLT2i represents a promising research field with possible clinical relevance.
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Affiliation(s)
- Vincenza Spallone
- Division of Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
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